Attach_04_Voucher_Review_Sheet.docx
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- Attached to
- Substance Abuse and Mental Health Services Indefinite Delivery Indefinite Quantity (SAMHSA IDIQ)
- Solicitation number
- 283-17-1000
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Attach 4 - Voucher Review Sheet
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RFP No. 283-17-1000 Attachment 4 – Voucher Review Sheet
VOUCHER REVIEW SHEET
Contract No.:
Ref. No.
Contractor:
DUNS:
Received in DCM/OFR:
| X |
| Cost Reimbursement |
Today’s Date:
Fixed Price
Date Due in DCM:
IQC Work Order
Date Due in PSC/DFS:
Letter of Credit
Contract Financing
(N/A if letter of credit)
To: __________________, Contracting Officer Representative (COR)
From: ____________________, Division of Contracts Management, OFR, SAMHSA, 5600 Fishers Lane
Subject: Voucher No. ________________ Period Covered: __________________________________ Contractor Point of Contract: ______________________ Telephone: _______________ Email: ________________
COR:
Please review the Voucher, answer the following question and return to DCM by the date shown above.
| YES |
| NO |
| 1. Are costs commensurate with efforts expended? |
| _____ |
| _____ |
| 2. Are all elements of cost reasonable, in support of contract performance and consistent with amounts negotiated? |
| _____ |
| _____ |
| 3. Have deliverables received during the period been timely and acceptable? |
| _____ |
| _____ |
| 4. Do you recommend payment be made as claimed? |
| _____ |
| _____ |
5. Do you question any costs claimed? If yes, explain below.
| _____ |
| _____ |
(ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED.)
COR sign and date here: ________________________________________ Date: __________________
| To: Program Support Center |
| PAY THIS AMOUNT: |
| _______________________ |
| DFO Accounting Operations |
| AMOUNT CLAIMED: |
| _______________________ |
| AMOUNT TO BE SUSPENDED FROM PAYMENT: |
| _______________________ |
In accordance with the Prompt Payment Provisions (Subsection (b)(4)), INTEREST [ ] IS / [ ] IS NOT payable under this Invoice or “Contract Financing Payment.” TO BE PAID NO LATER THAN _____________________.
* NOTE: THIS INVOICE/VOUCHER IS APPROVED FOR PROVISIONAL PAYMENT ONLY. All payments are subject to change pending final audit.
Reason for Suspension:
| Approved for payment: ______________________________________________ | Date: __________________ | |
| Contract Specialist |
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